| NPI | 1669765939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: MA DN1858899) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11202) |
| Enumeration Date | 2011-05-19 |
| Last Update Date | 2024-05-10 |